ethical leadership faculty guide - veterans affairs · 2019. 8. 8. · basil rowland, msw, lcsw...

FACULTY GUIDE

ETHICAL LEADERSHIP Fostering an Ethical Environment and Culture

National Center for Ethics in Health Care (NCEHC) Department of Veterans Affairs Washington, D.C. [email protected]

NCEHC Module Development Team Members:

Melissa Bottrell, MPH, PhD Chief, IntegratedEthics

Basil Rowland, MSW, LCSW IntegratedEthics Manager, Field Operations

Beth L. Doyle, MBAHealth Education Specialist

Ellen Fox, MD Chief Ethics in Health Care Officer

We wish to thank the following individuals for their contributions toward the learning design and production of this training content: Mary Kay Landon, Kerry Ouellet, Jamie Philpotts.

IntegratedEthics® is a registered trademark of the National Center for Ethics in Health Care.

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ii Fostering an Ethical Environment and Culture

Learning Objectives Aligned with IntegratedEthics® 4 Points of the Ethical Leadership Compass: • •

Understand the impact of ethical leadership behaviors on ethics quality in the organization. Practice behaviors that support ethics quality as reflected in the Ethical Leadership Compass. – – – –

Demonstrate that ethics is a priority. Communicate clear expectations for ethical practice. Practice ethical decision making. Support your local ethics program.

Application Objectives Participants are expected to apply the bulleted application objectives on the job. Demonstrate that ethics is a priority. • • •

Talk about ethics. Prove that ethics matters to you. Encourage discussion of ethical concerns.

Communicate clear expectations for ethical practice. • • •

Recognize when expectations need to be clarified. Be explicit, give examples, explain the underlying values. Anticipate barriers to meeting your expectations.

Practice ethical decision making. • • •

Identify decisions that raise ethical concerns. Address ethical decisions systematically. Explain your decisions.

Support your local ethics program. • • •

Know what your ethics program is and what it does. Champion the program. Support participation by others.

Module Overview Ethical leadership can be defined as activities on the part of leaders to foster an environment and culture that support ethical practices throughout the organization. Leaders play a critical role in creating, sustaining, and changing their organizations’ culture, through their own behavior and through the programs and activities they support and praise or neglect and criticize. All leaders must undertake behaviors that foster an ethical environment—one that’s conducive to ethical practices and that effectively integrates ethics into the overall organizational culture. To support this need, VA established the IntegratedEthics (IE) program, a national standardized, comprehensive, systematic, integrated approach to ethics in health care. This training module, oriented to the 4 points of the Ethical Leadership Compass, teaches leaders (High Performance Development Model [HPDM] Levels 2–4) essential ethical leadership skills to enable them to foster an ethical environment and culture in their local organizations.

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Fostering an Ethical Environment and Culture iii

Related Competencies With a focus on HPDM core competencies and learning principles, and incorporating elements of IE, this training will help VISN-level LEAD training program candidates improve their ability to foster an ethical environment and culture and, thereby, improve ethics quality within their individual organizations and across VHA.

Learning Level The IntegratedEthics curriculum for VISN-level leadership programs enables participants to apply new skills and exhibit behaviors consistent with ethical leadership. The content and objectives satisfy the requirements for Level 3 evaluation.

Module Delivery Ideally, participants would benefit from a multi-modal training that satisfies a variety of learning styles and abilities in a classroom environment. The following lessons should be offered after the participant has had a chance to read the 54-page Ethical Leadership primer and view the 45-minute Ethical Leadership video. Both of these materials are titled Ethical Leadership: Fostering an Ethical Environment and Culture. The accompanying ethical leadership breakout PowerPoint presentation has been successfully delivered on several occasions, and can be offered in part or as a whole by a facilitator who is familiar with the IE program. To find a local facilitator, facilities should contact their VISN IE Point of Contact (POC), who will be familiar with IE Program Officers in their Networks who have been recently exposed to this content. http://vaww.ethics.va.gov/docs/integratedethics/VISN_IE_Points_of_Contact_20071009.pdf

Sample Agenda 7:30–8:00a Registration

8:00–8:30 Welcome and Opening of the Ethical Leadership Training

8:30–9:00 Faculty and Participant Introductions

9:00–9:15 Training Introduction and “Ethics” and “Ethics Quality”

9:15–9:40 Compass Point 1: Demonstrate That Ethics Is a Priority

9:40–10:20 Compass Point 2: Communicate Clear Expectations for Ethical Practice

10:20–10:35 Break

10:35–11:05 Compass Point 3: Practice Ethical Decision Making

11:05–11:20 Compass Point 4: Support Your Local Ethics Program

11:20–11:30 Takeaways and Wrap-up

Module Development Date: November 2013 Suggested Citation: National Center for Ethics in Health Care. (2013). Ethical leadership: Fostering an ethical environment and culture. Washington, DC: U.S. Department of Veterans Affairs.

http://vaww.ethics.va.gov/docs/integratedethics/VISN_IE_Points_of_Contact_20071009.pdf

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iv Fostering an Ethical Environment and Culture

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ETHICAL LEADERSHIP Fostering an Ethical Environment and Culture

OB

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By the end of this session, participants will be able to:

Understand the impact of ethical leadership behaviors on ethics quality in the organization.

Practice behaviors that support ethics quality as reflected in the Ethical Leadership Compass.

RE

SO

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CE

S For the session:

Slide presentation, laptop, and projector

Participant Handouts

PR

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Gather training resources and read through the session plan.

Ensure that the laptop and projector are functioning properly.

SECTIONS DURATION (MINUTES)

OU

TL

INE

1 Introduction

2 “Ethics” and “Ethics Quality”

3 Compass Point 1: Demonstrate That Ethics Is a Priority

4 Compass Point 2: Communicate Clear Expectations for Ethical Practice

5 Compass Point 3: Practice Ethical Decision Making

6 Compass Point 4: Support Your Local Ethics Program

7 Takeaways

2

13

25

40

30

15

5

Total session time 130 minutes

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1. Introduction (2 minutes)

Slide 1

NOTE: Have this slide up before the session begins.

SAY:

Welcome to Ethical Leadership. Today we are going to talk about how you as leaders exemplify the vision of ethical leadership. We hope that you all are ready to think about and discuss ethical leadership concepts so that we can make this an active conversation. Please also feel free to ask questions at any time.

CLICK.

Slide 2

SAY:

“Ethical leadership” can be defined as activities on the part of leaders to foster an environment and culture that support ethical practices throughout an organization. Leaders play a critical role in creating, sustaining, and changing their organizations’ culture through their own behavior and through the programs and activities they support and praise or neglect and criticize. All people who aspire to lead effectively must undertake behaviors that foster an ethical environment—one that’s conducive to ethical practices and that effectively integrates ethics into the overall organizational culture.

ASK:

Now that we’ve given you a brief description of ethical leadership, how many of you have heard about an IntegratedEthics® or another ethics program in your facilities that builds and supports the practice of ethical leadership? What have you heard? What activities does it engage in?

ELICIT ANSWER(S): Answers may include programs that provide ethics education, manage an Ethics Consultation Service, address systemic issues in the facility that have ethical implications, and encourage ethics discussions at leadership meetings.

CLICK.

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Fostering an Ethical Environment and Culture 3

Slide 3

SAY:

Today, we’re aiming not only to make you familiar with the key concepts of ethical leadership but also to give you a chance to assess your own practices and practice some key leadership skills together.

We have anchored this session to the Ethical Leadership Compass, which is 4 specific behaviors leaders can use to foster a positive ethics environment. They are a core part of the IntegratedEthics program developed by the National Center for Ethics in Health Care at the Department of Veterans Affairs. Throughout the training, we will be referring to this office by its acronym, NCEHC. I’ll talk more about the IntegratedEthics (or “IE”) program in a minute. The 4 compass points are:

Demonstrate that ethics is a priority.

Communicate clear expectations for ethical practice.

Practice ethical decision making.

Support your local ethics program.

These concepts are listed on a handy bookmark that you’ll find in the front pocket of your Participant Handouts. They are explored in depth in the primer from the IE program, “Ethical Leadership: Fostering an Ethical Environment and Culture.” The primer is also available to non-VA users, and the link can be found on Handout 1: Links to Online Materials of the IntegratedEthics Program, Department of Veterans Affairs.

CLICK.

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2. “Ethics” and “Ethics Quality” (13 minutes)

Slide 4

SAY:

People give a variety of answers when asked the question, “What is ‘ethics’?”

ASK:

What does the word “ethics” mean to you?

ELICIT ANSWER(S): Answers may include morals, values, compliance, etc.

SAY:

As you see, answers include feelings, religious character, law, and so on.

CLICK.

Slide 5

SAY:

In the IntegratedEthics program, and for purposes of this session, ethics is:

The discipline that considers what is right or what should be done in the face of uncertainty or conflict about values. As you can see from the slide, we define “values” as strongly held beliefs, ideals, principles, or standards that inform ethical decisions or actions.

Ethics also involves making reflective judgments about the optimal decision or action among ethically justifiable options.

Ethical dilemmas might include the following:

Given that the attending thinks that the family has the right to determine what procedures are performed on their deceased relative’s body, but the chief resident believes that it will be good for the community if residents are allowed to practice procedures on newly dead patients, is it ethically justifiable to practice procedures on newly dead patients without consent from the next of kin?

Or:

What ethical concerns are raised by a draft hospital policy on advertising and what should be done to resolve them?

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What’s important is that ethics is an essential component of quality in health care. And I’m going to talk about that further in just a minute.

CLICK.

Slide 6

SAY:

Back in the early 2000s, NCEHC conducted a thorough review of VA ethics programs. Through that review, VA realized that we needed to change how we thought of the role of ethics in the organization. Some deficiencies that were identified included:

Lack of adequate training

Lack of a systematic approach to ethics analysis

Ethics program not well integrated into the organization

Ethics program lacking standards

Ethics program not improvement-oriented

Ethics program too narrowly focused on certain clinical areas

Ethics program not data-driven or lacking leadership support/accountability

From these findings, VA recognized the need to establish a national, standardized, comprehensive, systematic, integrated approach to ethics in health care across all of the VA medical centers. IntegratedEthics was designed to meet that need with the ultimate goal of achieving ethics quality.

There is an IE program in each of VA’s 140 integrated health care facilities.

CLICK.

Slide 7

SAY:

What do we mean by “ethics quality”?

When people think of quality in health care, they often think about technical quality and service quality. But in VA, we believe that there is a third component of quality—ethics quality.

For example, think about a patient who undergoes a surgical procedure. Let’s say that the procedure was perfectly executed from a technical perspective. And let’s say that the patient seemed quite satisfied with the result. But what if the patient was never informed—or even misinformed—about the nature of the procedure he received? That would be an example of good technical quality and good service quality, but poor ethics quality.

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So when we say ethics quality, we mean that:

READ the slide.

SAY:

See Handout 1 for the link to IntegratedEthics’ complete (yet succinct) definition of ethics quality.

CLICK.

Slide 8

SAY:

Achieving ethics quality in health care settings actually involves addressing policies and practices on 3 levels within the organization. You can employ the image of an iceberg to depict them. Only about 10% of an iceberg is actually visible above the waterline; the greatest part of its mass is hidden below.

Ethics quality in health care can be described in much the same way: Some ethical practices are readily visible; others become apparent only when we make an effort to see them. But what is usually unseen is the most important determinant of ethical practice overall.

At the surface, we can easily observe the decisions and actions made by everyone from top leaders and managers to line staff, and the actions that follow from them, in day-to-day practices. Those are the most visible examples of an organization’s ethical character.

Just under the surface are the systems and processes that drive decision making (including ethical decision making), and help make ethical decisions possible. For example, policies that reflect respect for families who have lost a loved one ensure that family members are not approached with an organ donation request when their deceased relative had expressed a preference against organ donation.

A facility’s environment and culture represent the deepest level. In ethical organizations, leaders create the climate where employees feel empowered to make ethically based decisions when confronted by a conflict of values.

Without good policies and practices at each of these levels, you will not get health care practices that are consistent with ethics standards, i.e., you will not have achieved ethics quality in your organization.

CLICK.

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Slide 9

SAY:

So let’s talk a bit about why ethics quality matters. Looking at data from our IntegratedEthics Staff Survey and VA’s All Employee Survey, we see strong correlations between employee perceptions that the organization for which they work is ethical and desirable ratings on a number of key quality metrics. Some of these “ethics quality benefits” (and the desired direction of employee ratings of these benefits) are listed on the slide. As you know, many of these metrics are directly associated with medical costs and quality of patient care, including patient safety.

For more information on how ethics quality relates to key performance metrics, see Handout 2: Ethics Quality Helps Build Healthy Organizations. This article was originally published in the summer 2013 edition of Organizational Health, a quarterly VA newsletter.

CLICK.

Slide 10

SAY:

The factors most closely associated with employee perceptions that they work in an ethical health care organization are either leadership behaviors, such as fair treatment of employees, or organizational aspects that can be influenced by leadership behaviors, such as the likelihood that employees will contact the ethics consultation service.

Questions we asked on the VA’s IE Staff Survey include:

Do managers follow up on ethical concerns that are reported by employees?

Can employees talk with supervisors about ethical concerns without fearing that their comments will be held against them?

This slide illustrates the association between some ethical leadership practices and the overall rating of the facility as an ethical organization. The longer the green bar, the stronger the association and more closely related it is to whether employees believe their organization is ethical.

Today, we are going to focus on the Ethical Leadership Compass—the core concepts of ethical leadership. We boiled it down into 4 general categories that we introduced at the beginning of this training. They provide a framework and some specific recommended practices.

CLICK.

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Slide 11

SAY:

Let’s talk about just a few examples of aspects of the organizational environment that influence ethics quality. Employees’ responses to 2 statements from the 2012 IE Staff Survey are shown on this chart. Respondents were asked to what extent they agreed with the following:

At this facility, employees can talk with supervisors about ethical concerns without fear of having their comments held against them.

At this facility, if an employee reported a potential ethics violation, managers would not tolerate retaliation against the employee.

These are perceptions that impact whether staff feel comfortable in their organization, a measure that has bottom-line impacts. You can see from the results shown on the bar graphs that agreement with these statements increased with supervisory level—a statistically significant trend. This finding is known as “rosier at the top.”

CLICK.

Slide 12

SAY:

This “rosier at the top” phenomenon was located in responses to many of the survey questions. For example, staff were also asked whether or not they agreed with this statement: “At this facility, I am reluctant to raise ethical concerns.” Again, results indicated that people at higher supervisory levels had significantly fewer concerns.

This trend is common in the literature nationally and internationally.

My point is—you as leaders matter to the organization. And how you practice ethical leadership is a big part of that. So let’s get to the core of this presentation.

CLICK.

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3. Compass Point 1: Demonstrate That Ethics Is a Priority

(25 minutes)

Slide 13

SAY:

Since today’s presentation is about ethical leadership, what do we mean when we say “ethical leadership”?

While virtually all leadership literature affirms that ethics is an integral characteristic of effective leadership, there’s no accepted single understanding of what ethical leadership is. Some talk about ethical leadership in terms of moral virtues or character traits. Others talk about certain management styles. Others talk about it in terms of how leaders use ethical decision models.

As we said at the beginning of the training, we define “ethical leadership” as activities on the part of leaders to foster an ethical environment and culture. But what do we mean by this? On the slide, we list some behaviors and beliefs that virtually everyone holds in a healthy ethical environment and culture.

We don’t think that ethical lapses come from bad apples or willful misbehavior. Rather, the ethical behavior of individuals is profoundly influenced by the environment and culture in which they work, and it is leaders that drive that environment and culture. This is why we are talking to you about ethical leadership and your role today.

CLICK.

Slide 14

SAY:

Let’s move on to the Ethical Leadership Compass.

By fostering leadership behaviors that help to drive an ethical environment and culture, we work to empower employees to do the right thing. In VA, ethical leadership uses the 4 compass points to help leaders think about and act in ways that foster an ethical environment and culture.

The compass, developed by VA’s NCEHC, applies insights and principles from organizational and business ethics to leadership in the context of health care ethics. It is specifically designed to orient leaders to their unique responsibilities in the terrain of ethics in health care and provide practical guidance for demonstrating behaviors that promote an ethical environment and culture across their organizations.

Each compass point is discussed in detail in the ethical

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leadership primer located in the Ethical Leadership section of the website for IntegratedEthics. The primer is the second link provided on Handout 1.

We’ll begin with the first compass point: “Demonstrate that ethics is a priority.”

CLICK.

Slide 15

SAY:

There are 3 overarching ways that leaders can demonstrate that ethics is a priority. This may seem obvious, but let’s look at some specific examples:

Talk about ethics: Say, “I see ethics as a priority,” or “We have an obligation to do the best we can for our patients.” Use words like mission, values, etc.

Prove that ethics matters to you: For example, treat everyone fairly; don’t play favorites. Maintain composure even in times of crisis, and demonstrate respect and consideration for others. Inappropriate behaviors include yelling at others and speaking disrespectfully about patients.

Encourage discussion of ethical concerns: Create formal opportunities for staff to discuss ethics. Explicitly signal that ethics is a legitimate and valued topic for discussion by saying, “Let’s talk about the ethical aspects of this problem.”

CLICK.

Slide 16

SAY:

So, let’s practice how we do this.

I’m going to read a couple of scenarios and I’d like you to think about how they may be good or weak examples of a leader demonstrating that ethics is a priority.

READ Case Scenario 1 off the slide (the “bad” example).

ASK:

Is this a positive or negative example? What makes it so? Can you critique what the supervisor has done?

ELICIT ANSWER(S): Answers may include:

This is a negative example.

Supervisor doesn’t talk to employee; supervisor sort of just brushes off the concern.

Supervisor doesn’t show any real commitment or

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interest.

Supervisor doesn’t engage the employee.

CLICK.

Slide 17

READ Case Scenario 2 (in which a leader demonstrates that ethics is a priority).

ASK:

Why is this a more positive example than the previous one?


Supervisor thanks employee for raising the concern.

Supervisor engages the employee and spends time to obtain information.

Supervisor says when he will get back to the employee and creates next steps.

Supervisor clearly makes this a priority and is transparent with his commitment to letting the employee know what he finds out.

Supervisor closes the loop.

Leaders may believe that they are demonstrating that ethics is a priority, but if you think about the leaders that you know, there are probably just a few that really stand out as doing this well.

ASK:

Can you think of any more examples of how leaders can demonstrate that ethics is a priority?

NOTE: Take a couple of suggestions from participants before moving on.

CLICK.

Slide 18

NOTE: Display this slide throughout the activity.

SAY:

This activity is based on Handout 3: Ethical Leadership Self-Assessment Tool, or ELSA. The link to the ELSA tool is also listed on Handout 1. We have included this copy of the complete tool to make it convenient for you to fill it out once you have returned to your facility.

The ELSA helps you to identify ways to model ethical leadership behaviors and develop an action plan to work on 1 or more of these areas. In today’s activity, we are going

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to take on a small chunk of the ELSA. You are going to think about 2 leaders in your organization: 1 whom you believe displays good ethical leadership practices, and 1 who displays poor ethical leadership practices. Think about behaviors they’ve exhibited that have had a positive or negative effect on the organization’s ethical environment and culture. Then consider 1 practice that you would like to improve, and get feedback from your peers on how they think you might do that.

Take out Handout 4: Leadership Behaviors and the Organization’s Ethical Environment Activity.

ACTIVITY: Receiving Peer Feedback (refer to Handout 4)

Groups Arrange group into pairs.

Time 10 minutes for group work

10 minutes to debrief with the large group

Total: 20 minutes

Before the Activity:

Give the following instructions

SAY: First, take a few moments and think of 2 leaders within your organization—1 who models good ethical leadership practices, and 1 who models poor ethical leadership practices.

The handout contains excerpts from the 4 compass points. They detail specific good ethical leadership practices emphasized in the IntegratedEthics program.

In the first column, place check marks next to those practices that your positive role model has used in the course of daily work. In the second column, place checks marks next to the practices that your negative role model has not used.

DISPLAY the handout and indicate the location of the columns.

SAY: For example, a leader engages in a positive ethical leadership practice by asserting publicly to staff that resources will be found to support a new initiative if it is the “right thing to do.” A negative example is the leader privately instructing a small group to do “whatever it takes” to report results that meet a specific performance measure.

PAUSE to allow sufficient time for participants to check the boxes.

SAY: So, thinking about that positive role model, please consider which practice you would like to improve upon or develop more fully within yourself, and place a check mark in the third column next to that action behavior/characteristic.

DISPLAY the handout again and indicate the location of the third column.

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SAY: Your task is to work collaboratively to formulate 2 or 3 specific actions to help you achieve the ethical leadership behavior you have just identified as the one you would like to improve, offering suggestions for how to achieve these as appropriate.

For example: If, in the first compass section, Demonstrate that ethics is a priority, you marked that you would like to improve upon “Holding your staff accountable for meeting high ethical standards,” you will ask the person next to you, “What would you recommend that will help me hold my staff accountable for meeting high ethical standards?” Or respond to their question. Your turn will to ask will come in a minute.

Hopefully, you will be able to come up with a few ideas or “nuggets of wisdom” like, “You can add ethics-related items to their performance reviews,” or “You can provide some kind of reward system for members of your staff that are meeting the high ethical standards.”

During the Activity:

Monitor

Monitor the pairs to ensure they understand the task. You may provide guidance during this activity to help participants succeed.

Call time at 1 minute and ask the pair to switch roles. Depending on the time available, ask participants to repeat the process 2 or 3 more times with different partners.

Following the Activity:

Debrief

Have the participants return to their seats. Summarize this activity by gathering a couple of responses from the group about specific compass-point items and their corresponding action behaviors that people shared with each other.

CLICK to the next slide.

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4. Compass Point 2: Communicate Clear Expectations for

Ethical Practice (40 minutes)

Slide 19

SAY:

Moving on to the second compass point, one of the most important ways that you can foster an ethical environment and culture is by making your expectations for ethical practice clear, explicit, and practical.

This second compass point is “Communicating clear expectations for ethical practice.” Of course the first thing you have to do is anticipate when expectations need to be clarified. Once you do, you then have to be explicit, give specific, personal, and real-life examples, and explain the underlying values. And then you have to anticipate the barriers and make it clear that you want to hear about problems so that you can help address them. When leaders don’t acknowledge the real-life barriers (e.g., “I expect 100% compliance, no excuses”), bad things can happen.

Let’s discuss some examples. As we go through the examples below, you can refer to the bullets that are included on Handout 5: Communicate Clear Expectations for Ethical Practice and use the space provided to make notes.

CLICK.

Slide 20

SAY:

Read the example on the slide to yourselves, and as you do, think about whether or not the leader’s message includes the following important points:

ASK and ELICIT ANSWER(S): Proceed through the following list. Answers should include:

Makes expectations explicit? Not at all

Gives examples? No

Explains the underlying values? No

Anticipates barriers? No

CLICK.

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Slide 21

SAY:

Now let’s look at Example 2. As you read, think about whether or not the leader:

ASK and ELICIT ANSWER(S): Proceed through the following list. Answers should include:

Makes expectations explicit? Yes

Gives examples? Yes

Explains the underlying values? Yes—confidentiality, compassion, etc.

Anticipates barriers? Yes

CLICK.

Slide 22

SAY:

You can see here we’ve color coded this example to show how this leader:

Blue—makes expectations explicit: In other words, the supervisor discusses under what specific circumstances employees should do or not do something, and describes the standard as simply as possible.

Green—gives examples: The supervisor presents a real-life situation with which employees can identify when they may be uncertain about the right thing to do.

Yellow—explains the underlying values: The supervisor gives not just a buzzword but a real, compelling, and principled explanation of why employees should do this.

Red—anticipates barriers: At a minimum, the supervisor tells employees what to do if they have problems. Even better, the supervisor anticipates the specific problems employees might have in trying to follow this directive. They communicate that they understand what the challenges are going to be.

Note that in real life these elements may not fall into such a neat order!

CLICK.

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Slide 23

NOTE: Display this slide throughout the activity.

SAY:

Now we’re going to do an exercise that is more challenging and also a little closer to the leadership communications you’re used to.

Take out Handout 6: IntegratedEthics Compass Point 2.

NOTE: This directive is fictional although obviously resembles real-life examples from VA.

CLICK.

ACTIVITY: Communicating Clear Expectations for Ethical Practice (refer to Handout 6)

Groups Arrange groups of 4 or 5.

Time 20 minutes for group work


Total: 35 minutes



SAY: Read Handout 6. Draft a script for a presentation to your staff that gives explicit expectations, offers specific examples, explains the underlying values, and anticipates/addresses barriers.

Remind the group to develop their script as a speech that they’d say at a meeting; they should not rewrite the memo.


Monitor

Monitor the groups to ensure they understand the task. You may provide guidance during this activity to help participants succeed.


Debrief

When group work is complete, have each group read its script out loud. Discuss strengths and weaknesses of the scripts, focusing on what worked well and what did not.


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Slide 24

SAY:

Review the sample script on the slide. It was drafted by one of the teams in our first set of workshops.

NOTE: Give the group approximately 2 minutes to read the script.

ASK:

Is there anything in the sample script that you find effective?

ELICIT ANSWER(S): Ask clarifying questions as necessary to engage the group. If no one speaks up, see examples below.

Examples may include:

It was very personal, the leader conveyed that he cared about staff.

It does a good job with the values, using inspirational and compelling language such as “need to protect,” “whether...patients can trust us….”

Gives contact information.

ASK:

What about this sample script do you think could be improved?

ELICIT ANSWER(S): Examples may include:

The script should acknowledge the effects the directive will have on people (barriers).

It should set explicit expectations or examples.

CLICK.

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5. Compass Point 3: Practice Ethical Decision Making

(30 minutes)

Slide 25

SAY:

“Practice ethical decision making” is the next compass point of ethical leadership.

To practice ethical decision making, you should:

Identify decisions that raise ethical concerns. These may be identified by an intuition that something isn’t right, a substantive difference of opinion about the right course of action, or the prospect of a harmful or inequitable outcome.

Address ethical decisions systematically. Without a systematic, transparent process, decisions can be mistakenly perceived as capricious, arbitrary, and unfair.

Explain your decisions. Tell stakeholders about both the process used to make the decision and the reasons why certain options were chosen over others.

Let’s take a closer look at that first bullet point.

As leaders, you make decisions all day long. But, what is special about decisions that require ethical decision making?

Some leaders refer to these as the “60 percent vs. 40 percent” decisions, as opposed to the “90 percent vs.10 percent” decisions. In other words, they are the difficult ones involving competing values where the right action is not obvious.

So what makes a decision an “ethical decision”? It’s when you are confronted by—and need to resolve—uncertainty or conflict about values. As we mentioned previously, values are strongly held beliefs, ideals, principles, or standards that inform ethical decisions or actions.

CLICK.

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Slide 26

SAY:

The thumb drive exercise helped to highlight some values that arise when leaders make decisions. Examples of values that emerged in the previous exercise were confidentiality and compassion. This slide shows others as well.

Decisions of all types raise ethical concerns, some of which are easily identifiable while others are not quite so explicit or may, in fact, only be implied.

Leaders can help to ensure that their decisions are sound and adequately address explicit and implicit values by using a systematic decision-making process.

CLICK.

Slide 27

SAY:

For our discussion about this compass point, we are going to focus on the difficult aspect of ensuring that the decision is values-based. Let’s unpack what that means.

Importantly, the more controversial a decision is, the greater the need for your decision-making process to systematically address and consider values (or take them into account).

This slide shows VA’s core values; of course, there are a lot of other implicit values. For example, why do we care when the inspector general is coming? What is the value there?

Handout 7: Definition of Values lists selected values with brief descriptions for each. The link to VA’s “I CARE” core values is listed on Handout 1.

CLICK.

Slide 28

SAY:

Next, we are going to do an exercise that will help you to practice both making values explicit and addressing those values systematically.

In this exercise, we want to illustrate how the need to address a decision systematically increases for decisions that are especially value-laden. This isn’t meant to simulate a good decision-making process; we aren’t giving you enough information to actually decide the case, and there is no “right answer” based on the information given.

Take out Handout 8: Values Cases.

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ACTIVITY: Values Case Study (refer to Handout 8)

Groups Arrange groups of 3 to 5.

Time 15 minutes for group work (7 to 8 minutes per case)


Total: 30 minutes



SAY: Read Values Case 1 on Handout 8. Taking no more than a minute, decide as a group whether or not VA should perform the vasectomy reversal.

For each group, your charge is to first decide what values should be considered in deciding how to respond to the Veteran’s request.

Then, write down a few sentences that make an argument for the values-based position of the other position (the one the group did not select). Don’t just use labels; use inspirational and compelling language. In other words, the pro team should try to articulate the values of the con team, and vice versa. Feel free to use Handout 7 that we just reviewed as a “cheat sheet.”


Monitor

Monitor the groups to ensure they understand the task. You may provide guidance during this activity to help participants succeed.

After approximately 7 minutes, ask the groups to read Values Case 2 on Handout 8 and inform participants that they will need to decide as a group whether or not to report the patient’s intentions to the appropriate authorities. Repeat the rest of the instructions as necessary.

Based on time and group dynamics, you may choose to have groups discuss only 1 of the 2 case studies.


Debrief

Reconvene the entire group after 15 minutes. Ask for volunteers from both “camps” to read their arguments for the opposing position aloud and give people in groups supporting that position the chance to respond and confirm whether or not the group’s values have been represented.

Then, ask participants to step back and discuss the relevance of values in making their cases—pro and con. Ask them to consider if they could make a convincing argument without invoking values.

Other points to cover include whether it was more powerful/effective to raise values (1) implicitly, (2) explicitly using abstract labels (such as “autonomy”), or (3) by building the inspirational value into the defense of the position, such as, “We owe it to our Veterans.” Ask participants to give examples that illustrate their process of articulating a values-based position, and whether this process helped them shift away from a “gut reaction.”

Next, engage the group in a discussion of what they discovered in trying to articulate the values of the opposing group. Explore whether this exercise influenced participants’ perceptions about the “right thing to do” and whether it helped them make the case for considering the values of all stakeholders in making an ethical decision.


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Slide 29

SAY:

From this exercise, we hope you take away that the more “value-laden” an issue is, the more important it is to address the decision systematically.

As you can see, people can take either side on these cases, depending on which competing value they embrace. Now that we’ve unpacked what a values-based decision may look like, let’s move on to how we can ensure our decision-making process is systematic.

CLICK.

Slide 30

SAY:

Understanding the values that people bring to the table is just one part of how we ensure that we are practicing ethical decision making. Ensuring that decisions are made using a procedurally just process is another key facet of ethical decision making. Procedural justice involves both fairness (in process and/or outcome) and transparency, and its practice has many positive impacts on the organization’s bottom line.

Importantly, research by Tom R. Tyler and colleagues found that giving disgruntled group members a voice— regardless of whether it influences the decision-making process—is sometimes enough for a process to be viewed as fair.

CLICK.

Slide 31

SAY:

So how do we get there? When you hear about a decision that you think is questionable, you may wonder whether the leader was ethical or, more often, you may criticize the decision-making process. For example, if you get a directive that you just don’t understand, you might challenge whether it was:

Informed: Did the leader use the full range of facts and understand the perspectives of all stakeholders?

Participatory: Did all those who have a stake in the outcome have input into the decision-making process?

Values-based: Did the leader explicitly consider and clarify the values and how those values relate to the decision?

Beneficial: Did the leader consider who would be benefited or be burdened by this decision?

Systems-focused: If you generalize this on a systems

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level would it make a good precedent?

Reasonable: How does this decision look to those not involved in the decision? Can the leader defend the decision to Veterans, external stakeholders, the media, or the general public?

These elements/characteristics (informed, participatory…) make up most ethical decision-making models in business, management, ethics, and other literature.

CLICK.

Slide 32

SAY:

Handout 9: Quality Check gives you a series of questions that you can use to ensure that your ethical decision-making process has addressed each of these elements.

To take our understanding a bit further, consider each of the following:

Knowledge: How informed should you be? How do you know if you have all the relevant facts? Are you questioning your own assumptions? You may need to:

Seek out consultants or multidisciplinary groups.

Examine data sets on root cause analyses, prior patient problems, or risk-benefit analyses.

Conduct Internet searches.

Examine your own personal background and leadership skills.

Participation: This includes anyone who is relevant or who may be affected by a decision. To satisfy this requirement, you may need to:

Engage a multidisciplinary model with representation from each stakeholder group.

Make sure you have canvassed each group.

Make the judgment regarding who to involve.

Values-based: Look at VA or other applicable core values. Although people tend to shy away from the term “ethics,” you should recommend deliberately addressing the values behind the conversation.

As leaders, you are asked to address ethical decisions systematically. The more controversial the decision, the more systematic the decision-making process needs to be. To ensure your decision-making process is systematic, you may need to seek consultation or expertise from an ethics-related service or office.

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Slide 33

SAY:

Determining which service or office from which to seek assistance may be difficult due to many factors. In VA, for example, the term “ethics” is used by a wide variety of programs and offices (e.g., designated agency ethics official [DAEO], Government Ethics, IE, etc.)—and it can mean very different things. For this presentation, our definition of “ethics” is the discipline that considers what is right or what should be done in the face of uncertainty or conflict about values. Also, ethics involves making reflective judgments about the optimal decision or action among ethically justifiable options

To help you, see: Handout 10: Triage Tool for Ethics-Related Leadership Decisions to help leaders sort through these services and obtain appropriate assistance. This tool is also available online; its link is listed on Handout 1.

CLICK.

Slide 34

SAY:

So what is the purpose of this tool?

Well, many leadership decisions relate to ethics. But only a subset of these decisions presents true ethical dilemmas—where there is uncertainty or conflict about values, and the right thing to do is unclear.

Other leadership decisions relate to ethics in a different way. For example, some relate to a systems-level ethics quality gap (a disparity between current practices and ideal practices from an ethical perspective).

Others relate to Government Ethics (legal standards of ethical conduct for employees of the executive branch).

And still others relate to a report or evidence of an ethics violation (allegation or evidence of a serious risk to patients, administrative misconduct, or noncompliance with legal or regulatory standards).

Each of these types of ethics-related decisions needs to be handled differently and involves different organizational offices.

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Slide 35

SAY:

Take out Handout 10. When confronting an ethics-related leadership decision, the first thing a leader must do is determine the type of decision that needs to be made.

So, starting with the rounded rectangle at the top of the page:

First, a leader becomes aware that an ethics-related leadership decision needs to be made.

Moving down to the next rectangle, the leader considers how the decision relates to ethics, in other words, to which category it applies.

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Slide 36

SAY:

The 4 categories (appearing in the next 4 diamonds) are:

A decision that relates to an ethical concern

A decision that relates to a systems-level ethics quality gap

A decision that relates to Government Ethics

Or a decision that relates to an ethics violation

Notably, sometimes a decision may be more than 1 type.

Once you have determined what type of ethics-related decision is required, you can then follow the arrows below each diamond to determine where to access the appropriate sources of expertise.

So let’s follow the steps on the tool for the first type of decision—a decision related to an ethical concern.

CLICK.

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Slide 37

SAY:

For this process, in particular, leaders should use the Ethical Leadership Quality Check (Handout 9) to consider if they have the important facts, have involved all relevant stakeholders, and can provide a strong ethical justification for the decision based on organizational and professional values, positive and negative consequences, and other factors.

As you can see, the Quality Check is also built right into the Triage Tool, and it can help leaders employ an appropriately systematic decision-making process that is informed, participatory, values-based, beneficial, systems-focused, and reasonable.

CLICK.

Slide 38

SAY:

Determining the level of engagement needed from others will depend on the complexity of the decision and other factors. For controversial issues, or those involving high-stakes ethics concerns, the decision-making process needs to be more transparent and inclusive. In such circum-stances, you will want to consult your local IE Council, Ethics Consultation Service, or other committee charged with considering ethics issues. If they lack the expertise, you might need to charter a special workgroup or use a formal decision-making framework.

Once leaders have all of the important facts, have involved all relevant stakeholders, and can provide a strong ethical justification, they may proceed to make the decision without seeking additional input.

Notably, regardless of the decision process used, leaders should communicate the decision to relevant stakeholders, and explain the decision-making process and ethical justification for the decision. In so doing, leaders help to ensure that everyone feels that they work in an ethical organization.

ASK:

Does anyone have any questions about the tool?

NOTE: Take approximately 2 minutes to answer any questions that participants might have.

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Slide 39

SAY:

Now that we’ve walked through the “ethical concern” track of the Triage Tool, we will work with some examples. More examples are included on the “Decision Exercise: Triage Tool for Ethics-Related Leadership Decisions,” which is available from NCEHC’s website. You can find the link on Handout 1.

So let’s practice using the tool now. From the front pocket of your Participant Handouts binder, please take out the 4 pieces of paper marked “A,” “B,” “C,” and “D.” First, I am going to read different scenarios off the slide. Then you’ll determine what type of decision must be made.

If the decision relates to an ethical concern, you should hold up letter A.

If the decision relates to a systems-level ethics quality gap, you should hold up letter B.

If the decision relates to Government Ethics, you should hold up letter C.

And if the decision relates to an ethics violation, you should hold up letter D.

As you hold up your letters, think about which service or office you would seek assistance and expertise from (for example, for VA participants, this could include CBI, medical inspector, or DAEO).

CLICK.

Slide 40

SAY:

For this and all of our examples today, we are going to assume that the appropriate supervisory chain of command has been followed (for example, supervisor, chief of service line, chief of staff, Human Resources).

READ the example on the slide.

ASK:

What type of decision must be made? Also, from which specific service or office would you seek assistance?

SAY:

Note the letter choices that go with each type of decision on the bottom of the slide.

NOTE: Encourage participants to hold up their letter choices.

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Slide 41

SAY:

So the correct answer is B. This decision relates to a disparity between best ethics practice and current ethics practice resulting from a system or process failure. To elaborate a bit, best ethics practice is an ideal established on the basis of ethical standards, norms, or expectations for the conduct of an organization and its staff. To address this disparity, it would be appropriate to refer this issue to the IE Preventive Ethics Team or other quality improvement mechanism.

(We will talk later about the IE structure, including the Preventive Ethics Team.)

ASK:

Do you have any thoughts on this particular example?

Did anyone select a different answer?

Do you have any questions or discussion points for this particular example?

NOTE: Allow a couple of minutes for discussion, and resolution of conflicting opinions.

SAY:

Let’s go now to Example 2.

CLICK.

Slide 42


ASK:

What type of decision must be made, and which specific service or office would you seek assistance from?

CLICK.

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Slide 43

SAY:

So the correct answer is A. This decision relates to uncertainty or conflict about values when the “right thing to do” is unclear. Because the supervisor is unsure about how to apply the policy within her allowed discretion, it would be appropriate to request an ethics consultation to discuss the range of ethically justifiable options.

ASK:




NOTE: Allow a couple of minutes for discussion and resolution of conflicting opinions.

SAY:

Moving on to Example 3…

CLICK.

Slide 44


ASK:


CLICK.

Slide 45

SAY:

So the correct answer is D. This decision relates to a report or evidence of a violation of an ethical standard. Specifically, there is an allegation of unprofessional behavior, which is a type of administrative misconduct.

As a general rule, this type of allegation is best handled within the supervisory chain of command (for example, by the chief of staff). If you are the leader responsible (or the supervisor with leadership authority) over the service/area that generated this question, it is your responsibility to investigate the situation and identify an appropriate course of action.

Sometimes a leader may convene an administrative

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investigation board to determine the facts of the case. In contrast, allegations of serious waste, fraud, or abuse as well as allegations of criminal activity should be referred to the inspector general or law enforcement authorities. Concerns about unprofessional behavior may also be referred to an appropriate state licensing board.

If you need information about professional ethics standards, you can request assistance from the Ethics Consultation Service.

ASK:




NOTE: Allow a couple of minutes for discussion and resolution of conflicting opinions.

SAY:

Moving on to Example 4…

CLICK.

Slide 46


ASK:


CLICK.

Slide 47

SAY:

So the correct answer is C. This decision relates to a legal question about standards of ethical conduct for employees of the executive branch—in this case, the rules on accepting gifts. Legal advice on Government Ethics rules must be obtained from the DAEO or Regional Counsel. If the DAEO determines that accepting a gift would be legally permissible, there might still be uncertainty or conflict about whether accepting the gift is the “right thing to do,” in which case it would be appropriate to request an ethics consultation.

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ASK:




NOTE: Allow a couple of minutes for discussion, and resolution of conflicting opinions.

SAY:

Thank you for that great discussion. We’ll move now into Compass Point 4.

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6. Compass Point 4: Support Your Local Ethics Program

(15 minutes)

Slide 48

SAY:

Leaders must demonstrate their commitment to ethics by supporting their local ethics programs and their activities.

If leaders are not seen by all staff to actively support the formal ethics programs and structures in a facility, these programs will not succeed…and the informal ethics environment will not improve.

Leaders can do this in 3 ways:

1. They should understand the ethics program, including the role of the Ethics Consultation Service, the role of preventive ethics (or other ethics-related improvement function), and how the IE Council (or other ethics-related leadership body) works.

2. They should be an outspoken champion for the program (e.g., by emphasizing the program’s role in helping employees instead of policing them and providing feedback to top leadership about the quality and effectiveness of the program).

3. Finally, they should encourage their staff to participate in the program and offer resources as appropriate to ensure the program’s success. They can demonstrate this support by making time available for employees to participate in their ethics programs and recognizing and rewarding employees for their ethics-related activities and accomplishments.

CLICK.

Slide 49

SAY:

Let’s take a closer look at that first bullet point in the context of that image of the iceberg that we discussed earlier. As you hopefully recall, there are 3 levels where ethics quality in an organization manifests itself.

Many ethics programs focus mostly on the surface layer, that of decisions and actions. But we believe this is a mistake. To be truly effective, an ethics program must address all 3 levels at the same time, including the deepest layer (that of environment and culture), which is often the most important determinant of ethical practice overall—and which is profoundly impacted by leaders’ words and actions.

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Leaders should demonstrate their commitment to ethics by supporting these 3 levels of their local ethics program and its activities. For example, leaders should be able to explain to others the fundamental concepts of their ethics program and how it operates at the 3 levels. They should also know who is responsible for each component of the program, and when and how to contact them.

CLICK.

Slide 50

SAY:

In VA, as we have said, the ethics program is IntegratedEthics. Its 3 core functions respectively support each level of the ethics quality iceberg shown here: ethics consultation addresses decisions and actions; preventive ethics addresses systems and processes; and ethical leadership addresses environment and culture.

CLICK.

Slide 51

SAY:

The Ethics Consultation Service is available to respond to specific ethics questions. Ethics Consultation Services handle ethics case consultations that relate to the care for a particular patient and other types of consultations, including requests for general information, policy clarification, document review, discussion of hypothetical or historical cases, or ethical analyses of organizational ethics questions.

In VA, the ethics consultation function uses the CASES approach to respond to ethics questions in health care. Ethics consultation is available to support leaders, staff, patients, and families when they have to make decisions and actions that might involve values conflicts.

POINT TO the image of the poster on the slide.

This is an example of a flyer promoting the Ethics Consultation Service that is used by VA. It is available on the NCEHC website and the link is listed on Handout 1.

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Slide 52

SAY:

The role of the facility’s Preventive Ethics Team is to address ethics quality gaps on a systems level. In non-VA settings, this could be a quality improvement function that looks at issues through an ethical lens. Preventive ethics applies quality improvement methods to produce measurable improvements in the organization’s ethical practices by implementing systems-level changes that reduce disparities between current and ideal practices. IE uses the ISSUES approach to address ethics quality gaps on a systems level.

Examples of ethics quality gaps that might be appropriate for preventive ethics include:

A recent audit found that only 10% of outpatient requests for assistance with completing advance directives are followed up on by clinic staff.

The quality manager for surgical services found a number of instances where adverse events that should have been disclosed to patients or surrogate decision makers were not disclosed.

Patients were being inappropriately and automatically charged a $50 co-pay for routine post-operative care covered within the global surgery period. Compounding the issue was that patients were not able to obtain a refund or were being referred to a collection agency for non-payment.

CLICK.

Slide 53

SAY:

You can call on the IE Council or other ethics-related leadership body if you believe you’ve seen a systems-level issue. The Council, as the central organizing structure for managing the IE program, provides integration for the program at 2 levels:

1. Integrates the 3 functions of ethics consultation, preventive ethics, and ethical leadership into a unified whole so that they work in a harmonious and interdependent way.

2. Serves as the facility’s hub and central clearinghouse for ethics activities, receiving and disseminating information and overseeing activities relevant to the ethics program. In this way, it integrates the IE program into the daily workings of the facility and, even, at the regional network (or VISN) level.

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Slide 54

SAY:

Now let’s discuss the other components of Compass Point 4, “Champion the program and support participation by others.”

A key factor in the success or failure of ethics programs is employees’ perceptions of management’s motivation for establishing the program. When employees perceive that the programs were created to help guide behavior and to establish a shared set of values and a positive culture, they are significantly more successful than programs that employees believe were designed primarily for compliance purposes.

Ethics programs cannot thrive if leaders do not champion them—so you need to participate in your IntegratedEthics or other ethics program.

ASK:

How, exactly, as an ethical leader, would you champion an ethics program?

What specific ideas do you have? Or, what have you seen that works?


Providing necessary resources, such as budget, space, clerical support, library materials, and ongoing training to help the program thrive.

Emphasizing the program’s role in helping employees instead of policing them.

Keeping up to date on program activities.

Contacting the Ethics Consultation Service or Preventive Ethics Team as needed.

Participating in education sponsored by the program.

Reacting positively when the program seeks input.

Supporting the program’s efforts to assess and improve its services.

Establishing clear lines of authority and accountability for the program.

Designating or hiring staff needed for key program roles.

Ensuring that these individuals have the knowledge, skills, and time they need to succeed.

Interacting with members of the program to respond to their needs.

Monitoring program performance to determine whether it is meeting its goals.

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NOTE: Mention any of the above points that are not offered by participants.

CLICK.

Slide 55

SAY:

Leaders at all levels should encourage others, especially employees who report to them, to participate in the ethics program and make use of the resources it offers.

ASK:

How would you support participation by others?

What specific ideas do you have? Or, what have you seen that works?


Reminding employees about IntegratedEthics or, as applicable, your local ethics program, and updating them about its activities.

Directing employees to the IE Council (or other ethics leadership body), the Ethics Consultation Service, or the Preventive Ethics Team, when appropriate.

Urging employees to participate in education sponsored by the ethics program.

Making time available for employees to participate in the ethics program and designating interested staff to participate.

Ensuring that employees who participate have ethics-related responsibilities in their performance plans.

Recognizing and rewarding employees for their ethics-related activities and accomplishments.

NOTE: Mention any of the above points that are not offered by participants.

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7. Takeaways (5 minutes)

Slide 56

SAY:

As we’ve discussed today, leaders shape the ethical environment and culture by what they do (and don’t do). You have all put in a lot of hard work completing the activities we’ve covered and you’ve done an excellent job practicing ethical leadership.

Remember, you can find more tools, job aids, and training on the NCEHC website. The link is listed in Handout 1.

Let’s spend a couple of minutes here at the end of this training to reflect on what you will take away from this session.

ASK:

What struck you as most important for your work as an EL leader?

ELICIT ANSWER(S): Answers may include any responses participants make. Take 2 or 3 responses, and as many more as time allows. Acknowledge each response.

SAY:

We have touched upon many concepts in this training. Hopefully, you have the materials you need to bring them all back to mind when you return to the job.

CLICK.

Slide 57

NOTE: Answer any questions and conclude the session with appreciation for the work participants have done and anything you want to say about your experience of the time you have spent with them.

ethical leadership faculty guide - veterans affairs · 2019. 8. 8. · basil rowland, msw, lcsw...

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